Appendix D to § 1910.146 - Sample Permits

Appendix D-1

        Confined Space Entry Permit
        Date and Time Issued: _______________ Date and Time Expires: ________
        Job site/Space I.D.: ________________ Job Supervisor:________________
        Equipment to be worked on: __________ Work to be performed: _________

        Stand-by personnel: __________________ ________________ _____________

        1. Atmospheric Checks:  Time      ________
        Oxygen    ________%
        Explosive ________% L.F.L.
        Toxic     ________PPM

        2. Tester's signature: _____________________________

        3. Source isolation (No Entry):  N/A   Yes   No
        Pumps or lines blinded,     ( )   ( )   ( )
        disconnected, or blocked    ( )   ( )   ( )

        4. Ventilation Modification:     N/A   Yes   No
        Mechanical                  ( )   ( )   ( )
        Natural Ventilation only    ( )   ( )   ( )

        5. Atmospheric check after
        isolation and Ventilation:
        Oxygen __________%           >    19.5   %
        Explosive _______% L.F.L     <    10     %
        Toxic ___________PPM         <    10     PPM H(2)S
        Time ____________
        Testers signature: _____________________________

        6. Communication procedures: ________________________________________
        _____________________________________________________________________

        7. Rescue procedures: _______________________________________________
        _____________________________________________________________________
        _____________________________________________________________________
        _____________________________________________________________________

        8. Entry, standby, and back up persons:              Yes       No
        Successfully completed required 
        training?
        Is it current?                                    ( )       ( )

        9. Equipment:                              N/A       Yes       No
        Direct reading gas monitor -
        tested                                ( )       ( )       ( )
        Safety harnesses and lifelines
        for entry and standby persons         ( )       ( )       ( )
        Hoisting equipment                      ( )       ( )       ( )
        Powered communications                  ( )       ( )       ( )
        SCBA's for entry and standby
        persons                               ( )       ( )       ( )
        Protective Clothing                     ( )       ( )       ( )
        All electric equipment listed
        Class I, Division I, Group D
        and Non-sparking tools                ( )       ( )       ( )

        10. Periodic atmospheric tests:
        Oxygen     ____%    Time ____  Oxygen     ____%    Time ____
        Oxygen     ____%    Time ____  Oxygen     ____%    Time ____
        Explosive  ____%    Time ____  Explosive  ____%    Time ____
        Explosive  ____%    Time ____  Explosive  ____%    Time ____
        Toxic      ____%    Time ____  Toxic      ____%    Time ____
        Toxic      ____%    Time ____  Toxic      ____%    Time ____

        We have reviewed the work authorized by this permit and the
        information contained here-in. Written instructions and safety
        procedures have been received and are understood. Entry cannot be
        approved if any squares are marked in the "No" column. This permit is
        not valid unless all appropriate items are completed.

        Permit Prepared By: (Supervisor)________________________________________
        Approved By: (Unit Supervisor)__________________________________________
        Reviewed By (Cs Operations Personnel) :
        _________________________________   ____________________________________
        (printed name)                             (signature)

        This permit to be kept at job site. Return job site copy to Safety
        Office following job completion.

        Copies:   White Original (Safety Office)
        Yellow (Unit Supervisor)
        Hard(Job site)
    

Appendix D - 2

          ENTRY PERMIT

          PERMIT VALID FOR 8 HOURS ONLY.  ALL COPIES OF PERMIT WILL REMAIN AT
          JOB SITE UNTIL JOB IS COMPLETED

          DATE: - -  SITE LOCATION and DESCRIPTION ______________________________
          PURPOSE OF ENTRY ______________________________________________________
          SUPERVISOR(S) in charge of crews   Type of Crew Phone #
          _______________________________________________________________________
          _______________________________________________________________________
          COMMUNICATION PROCEDURES ______________________________________________
          RESCUE PROCEDURES (PHONE NUMBERS AT BOTTOM) ___________________________
          _______________________________________________________________________
          * BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED
          PRIOR TO ENTRY*

          REQUIREMENTS COMPLETED                            DATE           TIME
          Lock Out/De-energize/Try-out                      ____           ____
          Line(s) Broken-Capped-Blanked                     ____           ____
          Purge-Flush and Vent                              ____           ____
          Ventilation                                       ____           ____
          Secure Area (Post and Flag)                       ____           ____
          Breathing Apparatus                               ____           ____
          Resuscitator - Inhalator                          ____           ____
          Standby Safety Personnel                          ____           ____
          Full Body Harness w/"D" ring                      ____           ____
          Emergency Escape Retrieval Equip                  ____           ____
          Lifelines                                         ____           ____
          Fire Extinguishers                                ____           ____
          Lighting (Explosive Proof)                        ____           ____
          Protective Clothing                               ____           ____
          Respirator(s) (Air Purifying)                     ____           ____
          Burning and Welding Permit                        ____           ____
          Note:  Items that do not apply enter N/A in the blank.

          **RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS
          CONTINUOUS MONITORING**  Permissible  _________________________________
          TEST(S) TO BE TAKEN      Entry Level
          PERCENT OF OXYGEN        19.5% to 23.5% ___ ___ ___ ___ ___ ___ ___ ___
          LOWER FLAMMABLE LIMIT    Under 10%      ___ ___ ___ ___ ___ ___ ___ ___
          CARBON MONOXIDE          +35 PPM        ___ ___ ___ ___ ___ ___ ___ ___
          Aromatic Hydrocarbon     + 1 PPM * 5PPM ___ ___ ___ ___ ___ ___ ___ ___
          Hydrogen Cyanide         (Skin)  * 4PPM ___ ___ ___ ___ ___ ___ ___ ___
          Hydrogen Sulfide         +10 PPM *15PPM ___ ___ ___ ___ ___ ___ ___ ___
          Sulfur Dioxide           + 2 PPM * 5PPM ___ ___ ___ ___ ___ ___ ___ ___
          Ammonia                          *35PPM ___ ___ ___ ___ ___ ___ ___ ___
          * Short-term exposure limit: Employee can work in the area up to 15
          minutes.
          + 8 hr. Time Weighted Avg.: Employee can work in area 8 hrs (longer
          with appropriate respiratory protection).
          REMARKS:_____________________________________________________________
          GAS TESTER NAME       INSTRUMENT(S)        MODEL          SERIAL &/OR
          & CHECK #              USED           &/OR TYPE          UNIT #
          ________________     _______________    ___________      ____________
          ________________     _______________    ___________      ____________

          SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE WORK
          SAFETY STANDBY   CHECK #   CONFINED              CONFINED
          PERSON(S)                  SPACE     CHECK #     SPACE      CHECK #
          ENTRANT(S)            ENTRANT(S)
          ______________   _______   __________  _______   __________   _______
          ______________   _______   __________  _______   __________   _______
          SUPERVISOR AUTHORIZING - ALL CONDITIONS SATISFIED____________________
          DEPARTMENT/PHONE ___________________________
          AMBULANCE 2800  FIRE 2900    Safety   4901  Gas Coordinator 4529/5387